What have you been reading, hearing or TV viewing that has provoked some feelings of comfort or concern about what is happening in the world of medicine, medical care, treatment or science? Ethics is all about doing the right thing. Are you aware of any issues in medicine or biologic science which are being done right, could be improved or in fact represent totally unethical behavior?
Write about them here.. and I will too! ..Maurice (DoktorMo@aol.com)

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Monday, February 14, 2011

Should a Non-Identifiable Picture of a Patient's Body or Tissue be Posted on Social Media without Patient Permission?

[Note: This thread here is a copy of the Question I posted today on Medpedia and to which I encourage my visitors to go there and read the responses of the Medpedia subscribers to my question.]

Randy Cohen, columnist and ethicist, received the following request and then wrote about his response in his New York Times column "The Ethicist" Here was the request: "Some of my Facebook friends are medical students who post cellphone pictures of patients with what these friends believe to be comical maladies, with captions like 'A 5-foot-9 Hispanic male walks into a bar . . ' under a picture of a patient with a piece of rebar piercing his abdomen. The postings don’t include faces or names but still seem questionable. Doesn’t this violate patient privacy? NAME WITHHELD, NEW YORK"

Would a rebar piercing an abdomen be an identifying feature or would adding " a 5 foot 9 Hispanic male" make the picture identifying?

What if a photograph was published in a medical book without patient identification? If such book publishing of a picture of that placenta is legal, wouldn't holding up a placenta by a group of nursing students also be legal to publish on Facebook?

What are "identifying features" and if there are no identify features, would the INTENT of an unidentified body or body part on a social media be the guiding factor with regard to whether such public distribution is ethical or not? Would the intent to be funny or any other reason except for strictly educational intent be considered an ethical (and ?legal) violation of patient privacy? ..Maurice.

17 Comments:

I don't think that it is proper to post unidentified patient photos because I think that it increases the amount of distrust that people have with their healthcare providers. Distrust can cause significant harm, including patients delaying getting needed healthcare or not being honest about their medical history.

On another note, not only does it do damage in a general way, a lot of "anonymized" photos look like they would be easy to identify by the patient or someone who knows the patient. Those black bars over the eyes don't do much.

The provider patient relationship by its nature requires a level of trust and professionalism like no other. Providers use the mantra of we are professionals, you have to trust us like no other outside your family and YOUR welfare best interestis our only concern when we ask you to compromise your modesty and trust us. Using a patients pain, suffering, misfortune, and humiliation for their and the entertainment of their friends is anything but respecting those prinicples. You are either a professional or you are not. This is totallay inappropriate and unacceptable and they should be fired for violating the patients trust, rights, and the reason they are there, for their beneifit and health....fire them...alan

When I initially read the intro to this, I thought, "sure why not?" I guess I was thinking of people and patients who were no longer alive and the picture could be that (for example) of a tumor removed after the patient had died. When you hear of patients in the ER with an interesting case, or a placenta, I feel that definitely crosses many professional barriers. The least of which is that if you are constantly on your phone (taking pictures and sending them), that it gives the message that you are not interested in the patient, but merely interested in what they may have presented with that day. I feel like that leads to a downward spiral of how health care professionals look at patients, and how patients look at us. Although we learn by seeing, I think the only suitable answer to this is to develop a "photographic release" or something stating that they are aware that photos have been taken and may be published. Once this waiver is signed, it should be done in a manner that does not interfere with patient care.Corinna

Well, it seems to me that pictures used for medical / educational purposes seem harmless to me and I wouldn't mind seeing my own let's say liver on a medical website. But this is one thing and making a joke out of a patient is another. So, yes I think doctors can take as many pictures as they like and use them when they think it might save lives but whenever a picture like the one mentioned on the article appears anywhere they should track down the weirdo who did this and take their license away.

How is there even a question about this--see Patient Modesty. I have a suggestion for all of you who think you have the right to take surrepticious pictures of patients and their body parts with your cell phones or other technology and publish them.

Place a sign on your office wall in type large enough to read and language that is clear. Be sure it is also visible to your patients. Say you reserve the right to take pictures of the patient's body, without her/his knowledge or consent, and publish those pictures (also without their knowledge or consent) if you think this will make a contribution to medicine. Assure them you will keep it anonymous and you will decide by what process you will assure that anonymity.

What do you think your patients will say? How many of them will even disrobe in front of you? Who has appointed you to decide these things for your patients. What makes you even think these things might be ethical?

I have a simple test for all of you who would play God with your patient's bodies and personal information. Think about what your patient, the one you claim you will respect and not harm, would say if he/she was explicitly told of your planned actions in clear terms.

It is clear what I think of this, but I am just a potential patient. By the way, I think anyone who does this for any reason should be severely disciplined for ethical violations. If they do it for the purpose of making fun of a patient on Facebook, etc., they should lose their license. If a student, they should be expelled.

If you think there is need to take a picture of a specific patient for a specific reason, get permission. If you believe a picture would make a contribution that might benefit other patients, try explaining that to the patient when you seek consent. A patient might say no. They might also say yes.

Why do some health care providers have such a low opinion of patients? Patients who trust their providers may feel honored to help if they are told a picture might help others. Some patients won't want this, and that should be their right.

A health care provider's perceived need for a picture is not the point. The idea that any professional would take it upon themselves to decide what is, or isn't identifiable is outrageous, as is the idea that a physician has the right to decide if a picture is needed for publication of any sort. There is no way of knowing what in a picture might allow the person whose body (or body part) is displayed might make that picture identifiable.

Patients need to know they have a choice about who has access to their medical information. This includes pictures of their bodies and body parts. The body or body part a health care professional may want to display belongs to the patient and only the patient should make decisions regarding what pictures are taken and how they are used.

It seems to me that the notion that you don't need permission for this kind of thing is very dangerous. I stand by my previous statement.

You are misinterpreting my comment. What I'm suggesting is certainly most pics should never be takenBut I'm saying is this,it's irevelant wether it's identifiableOr not.Why and by whom took the pic in the first place.

Thanks for replying. I thought I might have misunderstood, but wasn't sure and felt a need to further clarify my own position. We may not disagree about this. I have no issue with taking pictures for use in education and research. Pictures enhance and at times are necessary to both. I have occasionally agreed to release identifiable information about me because I thought it would help a student. When I was supervising students, I sometimes had to ask patients for permission to record identifiable information. I have been at both ends of this discussion. The condition was always that the patient gave informed consent knowing how the material would be used and how it would be handled after its use. My entire issue is with disclosure and respecting patient choice.

This topic started as a discussion about taking pictures without patient knowledge or consent and was provoked by the posting of pictures ridiculing patients on Facebook. It is hard for me to imagine any ethical professional finding that practice acceptable, though they may disagree about the appropriate consequences.

The bigger question, I think, is the taking of surrepticious photos under the guise of needing them for purposes that might benefit other patients.

My concern, and my anger at some comments, is really related to the ease with which some agree that it is acceptable to secretly take pictures and publish them without the knowledge and consent of the patient. It related to the idea that if it is a body part, somehow that is unidentifiable so is ok. I also want to challenge a bit anyone who has the notion that since it would be ok with them, it isn't a problem. No doubt there are some patients who would have no problem with this practice. That doesn't mean people who would have a problem with this are out of line, or that any professional should be making those decisions for another.

I replied to this thread specifically because I am very concerned about respecting patient privacy and choice. I know our understanding of privacy has changed with the rapid changes in technology. It would be absurd not to use the new technologies that are available. The question is how, and the implications of each choice. I am very concerned that long-standing principles of confidentiality and patient choice are being turned upside down without stopping to really consider the potential consequences of precedents that are being set.

The new ideas of privacy, or lack of privacy, that result from social networking should not be quietly applied to medicine. I think professionals need to stop and think about how some of the new realities might be influencing their thinking and judgment in their handling of confidential patient information. My concerns don't just relate to pictures, but that is the topic at hand.

The idea that a professional might find a way to justify using their cell phone (or just a webcam in their computer?) to take pictures of patients without their consent is repugnant to me.

Certainly we are on the same page in this regardsand as a perfect example the nurses in Wisconsin whoposted a pic to facebook of an object lodged in a patient'srectum. The pic was of course taken without the patientspermission,yet even with permission from the patientwould be unethical as it serves no useful benefit.

I was born w/pais- look it up. If I found out that someone in the medical "proffesion" had posted any pics of me I would have them in court so fast their necks would snap! Patient/Doctor/nurse/etc.... confidentiality should not ever be in doubt. Too many children have suffered what is tatamaount to sex abuse by the "professionals" who stood them against a wall took pics blacked out their eyes and called it research. A persons body is their one true possession that should never be be violated by pictures or surgery unless absolutely needed. Too many times good intentions cause great harm. A sign in an office? Bullshit! What makes anyone think they have rights over me because of a sign! Just because the technology exists don't give people the right to use it how they wish. The true sad thing here is that this discussion has to take place. No one understands the meaning of privacy in the cyber age.

I fully agree with "Tea with Jim" regarding simply blacking out the eyes. I have always thought that considering that simple graphic action as a means of protecting patient privacy was some sort of "wishful thinking" at the most by the researcher and a waste of time for the graphic tech who created the picture for publication.

On the other hand, how can students, interns and residents be taught all the variable genital appearances of PAIS if photos are not available? Though certainly they should be obtained with the full permission of the patient or in the case of a child, the parent surrogate. And certainly only the part of the body excluding the face which is pertinent should be shown...Maurice.

I also agree with Tea with Jim. Just because the technology exists at no time gives anyone to publish any part of a patient's body without their consent. It does not matter that the part of the body could not be identified. To use this picture for humor I feel makes it much worse.It is a violation of their privacy and violates the trusting medical relationship.

Ok, this is not exactly on topic but it does go toward the emotional side of this debate.

My late grandmother donated her COPD and ETOH destroyed body to science. As a new nursing student, I found photographs of cadaver parts in my A&P classes difficult to look at. I am not a bit squeamish (spent many years as a wound and ostomy RN) but with any text published after her death, I would wonder.....Grammmy? Is that YOUR pulmonary system??

So I can imagine someone not in the business would be really creeped out, especially if there is not a shred of scientific learning behind the image.

I think you misunderstood my comment about a sign in the office. It was meant to be a bit sarcastic, not a suggestion of something that would be adequate to provide informed consent.

My point was directed toward comments that seemed to suggest if the intention of taking pictures was a good one (as defined by the person taking the picture), and the picture was unidentifiable (again as defined by the person taking the picture) that a surrepticious picture would be no problem.

In fact, I believe the opposite. My point was that if told directly that the doctor/provider reserved the right to take pictures without consent, most patients would refuse to even allow an examination. I know I would refuse.

My own history is such that I stopped providing personal information to "health care providers" when HIPPA retroactively took control of my medical records from me. Not only did HIPPA do this, but it was disguised by what I see as an elaborate scheme of smoke and mirrors that left people believing HIPPA protected their personal information. My stance on this has understandably caused problems for me on the rare occasion when I have to seek medical attention, but I believe HIPPA was a betrayal of the doctor-patient relationship and the participation of physicians in the hoax has left a lie as the basis of any interaction with a health care provider.

Even with my cynicism, I could not in my worst nightmares imagine pictures of me being surrepticiously taken without my permession, let alone taken and published.

I have historically been willing to consent to use of some of my personal information to help in training students, but that was always with my understanding exactly what would be used, to whom it would be given, and why.

I can think of no ethical justification for surrepticious pictures being taken in any circumstance. If a picture is to be taken for an ethical use, part of the ethics includes true informed consent.

Unless it's a before / after pic for cosmetic surgery, or something that's likely going to be presented in a criminal investigation (gubshot wound, bruised childs back, etc), then there should be NO reason to ever have any kind of camera anywhere near where a pt is in any sort of undress.

Even then, there is no excuse to take secret pics on a cellphone... if pics are nessesasry, use a highly visibile one that nobody can say they didn't see in the room.

Anyone caught taking secret pics shouldn't just lose their liscense.... they should also be criminally charged, as should anyone leaking "legitly taken" pics.

Imagine if the setting was changed, and you found out that a clothing store you shop in was secretly taking and posting online pics taken in the fitting rooms. They could always use the excuse that "it's for reseach purpouses, to help improve the layout and use of the fitting room, and help catch shoplifters"... would that make you ok with potentially having your pic taken?

It's not that I "don't" trust medical "professionals"..... I simply "CAN'T" trust them, which is why I haven't seen a doctor in over 10 years. Hearing about things like this isn't going to help my opinion of them anytime soon.

FTJ, is your concerns specifically related to the legal aspect of the subject not giving permission for photography or is your concerns primarily about your own physical modesty? If it is the latter, you may be interested to read and participate in an ongoing thread about patient modesty currently "Patient Modesty: Volume 54". ..Maurice.

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